P1707 Recommended Practice for the Investigation of Events at Nuclear Facilities

IEEE SC5 – Human Factors, Control Facilities and Human Reliability

PAR – Need For The Project Nuclear industry need for standard set of terms and features for event

investigations

Provide a common basis for the planning, conduct, and reporting of event investigations

Target audience: nuclear facility staff, management, and reviewers of event investigation reports

Will enable more effective use of data and results

Addresses both the investigation of specific events and causes, as well as the general organizational factors that may be relevant

Will support more timely and effective event investigations, both by individual facilities and by the overall industry, enhancing nuclear safety and productivity

Participants Carl Allesandro Terry Bartley Dorian Conger William Corcoran Robert Fisher Richard Foote Felicity Harrison Alex House Kay Wilde Palmer

(Vice Chair) Chris Kerr (Chair)

Angie Kozak Jack Martin Graem Meteer Mark Paradies Julius Persensky

(Chair) Robert Shular Olivier St-Cyr Pierre Tanguay Tracy Theesfeld Paul Wong

Julius Persensky

History and Status 2008 Working Group (WG) start 2008 – 2011Initial draft development 10/2011 First submittal to the SC-5 subcommittee 03/2012 Reissued PAR for date change and to

address minor errors in scope 10/2013 New WG 5.5 Chair appointed 10/2013 Significant re-write of document due to

SC5 reviews 10/2014 Revised document reviewed by WG and

SC5 12/2014 SC5 approved submittal of P1707 to

NPEC for preview to ballot

Table of Contents

1. Overview2. Normative References3. Definitions4. Event Investigation Process4.1 Establishing Roles and Responsibilities4.2 Planning

4.3 Information Gathering and Analysis4.4Cause Determination 4.5 Corrective Action Plan4.6 Investigation Reports4.7 RecordsAnnex A BibliographyAnnex B Common Cause Analysis

4. Event investigation process

4.1 Establishing roles & responsibilities◦ Senior management◦ Management sponsor◦ Line management◦ Investigation analyst◦ Team leader◦ Team members

4. Event investigation process

4.2 Planning◦ Early Actions Remedial actions; make facility safe Preservation of evidence

◦ Preparation for investigation Schedule requirements (e.g. ,60 day requirement

per 10CFR50.73 for LERs) Team formation Charter development

◦ Confidentiality, security and privileges

4. Event investigation process4.3 Information Gathering and Analysis◦ Information gathering Sources of information (e.g. ,logs, interviews)◦ Extent of condition Identify if condition exists elsewhere◦ Operating Experience Review of internal and external experience to

identify similar events◦ Analysis tools & techniques E.g., Event and causal factor charting, task analysis,

failure modes and effects analysis

4. Event investigation process

4.4 Cause Determination◦ Approach Develop link between event and cause(s)

◦ Extent of Cause Identifies where else cause may exist

◦ Safety Culture Evaluation of potential organizational health issues

which may have contributed to event Based on USNRC and industry (INPO, NEI)

guidance

4. Event investigation process

4.5 Corrective Action Plan◦ Directly linked to root and contributing

causes◦ Prevent or minimize potential for event

recurrence◦ Timely implementation

4. Event investigation process

4.6 Investigation Report◦ Attributes Report format and content

◦ Review and Approval Peer and management reviews

◦ Corrective Action Effectiveness Verify effectiveness of corrective action to prevent

event recurrence Completed after sufficient time allowed for actions

to be in place

4. Event investigation process4.7 Records◦ Suggested retention practices

Annex A◦ Bibliography of USNRC and industry

documents on root cause evaluations and safety culture

Annex B◦ Guidance for Common Cause Analysis◦ Separate analysis to identify cause for multiple

events

Milestones Going Forward 01/21/2015 Preview to NPEC 01/21/2015 Permission to Ballot vote 02/20/2015 Deadline for NPEC comments 03/16/2015 IEEE SA Ballot invitation 04/16/2015 Initiate IEEE SA Ballot 10/16/2015 Submit to IEEE SA RevCom 12/2015 RevCom meeting

Questions?